Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders

1. Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders Wayne W. Fisher University of Nebraska Medical Center’s Munroe-Meyer Institute

2. Autism and Childhood Schizophrenia • Once thought to be a form of schizophrenia • Differs from schizophrenia in terms of symptoms, age of onset, family history, etiology, and response to treatment

3. Definition of Autism • markedly abnormal or impaired development in: • social interaction • Communication • and markedly restricted repertoire of activities and interests.

4. Definition of Autism • Definitions are cheap, but explanations are dear, and we must be careful not to confuse them. • David Palmer, 2004

5. Prevalence of Autism • Typically diagnosed within first three years • Recent estimate indicate that the prevalence of ASD is between 1 in 38 and 1 in 88 • Four times more prevalent in boys than girls

6. Recurrence Risk for Siblings • If an older sibling has and autism spectrum disorder, the risk for a Younger brother is 1 in 4 Younger sister is 1 in 11

7. NIH Research Dollars Devoted to Autism • When Compared with Other Serious Childhood Conditions, Autism is Much More Common, but Fewer Dollars Per Case are Spent on Autism.

8. Prevalence of Autism and Other Conditions (Number of Cases per 10,000 Children) 70 60 50 40 30 20 10 0 Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

9. NIH Research Dollars for Autism and Other Conditions (Number of Dollars per Case) $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $- Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

10. Unfortunately, you have what we call “no insurance.”

11. Demographics of Autism • Affects all racial, ethnic, and national groups • Family income, lifestyle, and educational levels do not affect the chance of autism's occurrence • Diagnosis of autism is growing at a rate of 10-17 percent per year (U.S. Department of Education, 2002)

12. Assessment and Diagnosis of Autism • No medical tests for diagnosing autism • Accurate diagnosis is based on observation of the individual's communication, behavior, and developmental levels. • Autism Diagnostic Interview-R (ADI-R) • Autism Diagnostic Observation Schedule (ADOS) • Home and/or school observation • Video analysis of behavioral observation

13. Social Behavior Generally Requires Little or No Explicit Training

14. Assessment and Acquired Autism • Autism is most often diagnosed between 2 and 5 years of age. • Thus, it is natural for parents to look for environmental events occurring shortly before this time that may have caused the autism, such as childhood vaccines.

15. MMR Vaccines and Autism • 10 of the original 13 authors of the investigation that started the controversy have retracted the study’s interpretation, as has the journal, The Lancet • Prevalence rates of autism are equivalent in children who have and have not been vaccinated. • Increases in the prevalence of autism did not abate when thimerosal was removed from vaccines. • Regression in autism is no more likely in the months after the MMR vaccine than in the months before the vaccine.

16. Identifying the Genetic Bases of Autism Spectrum Disorders • Etiologic Workups Identify Specific Genetic Causes for Autism in About 20% of Cases. • At the Munroe Meyer Institute, Shaefer and Colleagues (2006) have developed a 3-Tiered Approach that Identifies Genetic Causes in 40% of Cases.

17. Associated Disorders Autism ASD • Mental Retardation 50% 15% • Seizure Disorder 35% 10% • Self-Injury, Aggression 50% • Tourette Disorder • Bipolar Disorder

18. Associated Etiologic Diagnoses • Fragile-X syndrome • Tuberous Sclerosis • Williams syndrome • Landau-Kleffner syndrome • Congenital Rubella • Smith-Magenis syndrome • Neurofibromatosis

19. Genetics and Twin Studies • Autism runs in families • Heritability for autism is about 90% • Monozygotic twin concordance, 60%-100% • Dizygotic twin concordance, 10% • Associated with abnormalities on chromosomes 7q, 2q, and 15q

20. Applied Behavior Analysis (ABA) • What is ABA? • How is it different from other approaches? • How is it Done?

21. How Effective is ABA for Autism? • About 50% of Children with Autism and no More than Mild Mental Retardation who Receive Early Intervention with ABA Attain Normal IQs and are Educated in Regular Classrooms with Minimal Assistance.

22. Outcomes of ABA for Autism 35 30 25 20 Increases in IQ Scores r = .79 15 p < .02 10 5 0 0 5 10 15 20 25 30 35 40 45 Hours per Week of Treatment

23. Cost-Benefit Analysis of Early, Intensive ABA for Autism • Average Lifetime Cost for a Person with Autism is over $4 million • Average cost of Early, Intensive ABA is $150,000 over about 3 years • Average Lifetime Savings from ABA Treatment is Between $1.6 and $2.7 million

24. Cost-Benefit Analysis of ABA treatment for Severe Behavior Disorders • Children with Autism and Severe Destructive Behavior Cost $8 million over a lifetime. • Keeping just one child out of chronic care pays for treatment of hundreds more. • Our treatment approach has over an 80% success rate.

25. Case Example (Costs since 1986) $4,050,000 4000 3500 3000 2500 2000 Dollars in Thousands 1500 1000 500 $85,924 0 Inpatient and Outpatient Costs Residential Costs Over 25 Years

26. Autism and Problem Behavior • 98% of children with autism have one or more of the following problems: • Feeding problems • Sleeping problems • Tantrums • Self-injurious behavior • Aggression Dominick et al. (2007)

28. Variables Related to Problem Behavior in Autism • Lower IQ scores were associated more problem behaviors • Lower expressive language scores were associated with more problem behaviors • Increased social deficits were associated with more problem behaviors Dominick et al. (2007)

35. Functional Analysis and Treatment of Aberrant Behavior

36. Structural vs. Functional Diagnosis • Structural Approach • How often a particular set of symptoms or responses cluster or covary. • Functional Approach • Whether and which environmental variables influence the response.

37. Functional Analysis • Identifies the environmental contexts in which aberrant behavior is likely and unlikely. • Identifies the consequences that reinforce and maintain the behavior. • Used to prescribe effective treatments.

38. Common Functions of SIB • Social Positive Reinforcement (Attention, Tangible items) • Social Negative Reinforcement (Escape) • Automatic Reinforcement (e.g., Sensory Stimulation)

39. Essential Features of Functional Analysis Conditions • Unique discriminative stimuli that signal the available of a specific reinforcer • Establishing operation (EO) that increases motivation for the specific reinforcer • An EO is an environmental condition that momentarily increases the effectiveness of a reinforcer and that evokes responses that have produced that reinforcer in the past. • Contingency between the target behavior and the specific reinforcer

40. Identifying the Essential Features of Functional Analysis Conditions • See if you can identify the discriminative stimulus, the establishing operation, and the reinforcement contingency in each of the following functional analysis conditions.

41. Attention Condition • Adult is busy reading. Child is expected to play quietly with toys. • Adult attention shifts to child following SIB (e.g., “Please don’t hit yourself”). • Determines whether adult attention functions as reinforcement for SIB.

42. Essential Features of the Attention Condition • Discriminative Stimulus: Adult is seated in a chair reading a book. • EO: Attention is unavailable. • Contingency: SIB produces attention.

43. Tangible Condition • Adult takes preferred toys or leisure materials from the child and returns them following SIB. • Determines whether access to preferred items functions as reinforcement for SIB.

44. Essential Features of the Tangible Condition • Discriminative Stimulus: Adult takes and holds the preferred tangible item at the start of the session. • EO: Tangible item is unavailable in the absence of SIB. • Contingency: SIB produces the tangible item.

45. Demand Condition • Child is prompted to complete non-preferred tasks by an adult. • The task is removed and the child is given a short break following SIB. • Determines whether termination of non-preferred activities functions as reinforcement for SIB.

46. Essential Features of the Demand Condition • Discriminative Stimulus: Instructional materials and demands are presented. • EO: Nonpreferred demands are presented. • Contingency: SIB results in temporary removal of the demands.

47. Alone Condition • Child is placed in a room alone without toys or materials. • Indirectly assesses whether SIB may be maintained by automatic reinforcement (e.g., sensory stimulation).

48. Essential Features of the Alone Condition • Discriminative Stimulus: Absence of another individual or materials. • EO: Alternative sources of stimulation are unavailable. • Contingency: SIB produces self-stimulation.

49. Toy Play Condition • Child and adult play together with preferred toys or leisure items. • Adult delivers praise about once every 30 seconds for the absence of SIB. • Designed to be an analogue of an “enriched environment”, which serves as a control condition.

50. Essential Features of the Toy Play Condition • Discriminative Stimulus: Adult and toys are near the individual. • EO (or AO): Attention and tangible items (toys) are freely available and no demands are presented. • Contingency: SIB produces no consequence.